ifteen
years ago the president of Chrysler complained: “I spend more
money for health care for every car I build than I do for steel.” Since
then health care costs in the U.S. have increased at a double-digit
annual rate. The University of Miami, after a year in which health
care costs rose
12 percent, faces an increase of 15 to 20 percent
for next year, as do small and large businesses and individuals
across the country. Individual health coverage is almost impossible
to get
and virtually unaffordable, exceeding $10,000 a year for a family.

Is there a crisis? It depends on who you are. Employers large and small
believe there is; the federal government continues to predict bankruptcy
in the Medicare program. Healthy and ill alike are so concerned about
losing health insurance that they stay in jobs they dislike.

But pharmaceutical companies, for-profit hospital
chains, some not-for-profit hospital systems, and some physicians have
experienced increased revenues
and profits and geometric increases in incomes. For these groups there
is no crisis; higher spending is just part of this country’s commitment
to the finest health care system in the world. But is it?

The enormous cost has not resulted in a system
the world envies. We rank No. 1 in health care expenditures, spending
more than 14 percent of our
gross domestic product ($3 trillion), while Germany spends 10.5 percent,
Sweden 9.2 percent, and Japan 7.1 percent (with the world’s highest
life expectancy). More than 20 percent of our residents lack health insurance;
an even greater number are underinsured. According to the World Health
Organization, we rank 28th in infant mortality and 72nd in “efficiency
of expenditures for health.” The cost of malpractice insurance
creates a suffocating burden in Florida and other states. In fact, many
believe we are on the brink of a crisis so profound that it may fundamentally
alter American health care.

What’s the solution? Governmental intervention such as that proposed
by the Clinton administration years ago could have helped control costs
and mandated universal health coverage, but clearly the time wasn’t
right. Other “top-down” approaches, including government
regulation of health care fees and imposition of a “single payer” system,
are unlikely to occur.

What are the alternatives? Many medium to large
employers are considering plans that place much of the cost in the
employee’s hands, along
with the choice of what kind of health care to seek and when. While attractive
financially, this places many employees at potential financial risk.
Others, like the University of Miami, are considering strategies that
would empower the patient/employee and his or her primary care physician
to provide comprehensive, preventive, and easily available care. The
assumption is that such care, from a physician well known to the patient,
would reduce unnecessary testing and referrals and decrease overall costs.
This strategy has much to recommend it, but there are serious obstacles.

There are few incentives for physicians to enter
primary care practice and fewer for those nearing “retirement age” to remain in
practice. More and more graduates of U.S. medical schools are choosing
specialties that pay higher salaries and provide more flexibility.

Our current reimbursement of physicians pays
well for care of the acutely ill and thus has created a subspecialty-oriented,
technologically rich
system of medicine. There are no incentives to promote wellness, prevent
or delay disease, and support patients in the lifestyle changes so
necessary for good health. Payment for office assessment, management
of complex
problems, and patient education is so low that both patients and physicians
feel rushed as visit volume increases to meet rising expenses.

Is it any surprise, then, that a health care
strategy that depends on a large number of high-quality, well-informed,
and motivated primary
care physicians supported by the latest information technology poses
at the very least a challenge? In the next issue of Medicine magazine,
I will describe a proposal being developed to address this critical challenge.

Laurence B. Gardner, M.D.,
is professor and chair of the Department of Medicine and vice dean
of the School of Medicine.